Goal of Therapy of Psoriatic Arthritis (PsA)
The goal of therapy is to achieve MDA or VLDA in the global assessment of PsA, or low disease activity using DAPSA if peripheral arthritis. Treat to target Clinicians must aim to achieve MDA in all patients as soon as possible – aiming for 50% improvement in disease activity score within 3 months, and target reached by 6 months. A treat-to-target paradigm should be followed to achi
The goal of therapy is to achieve MDA or VLDA in the global assessment of PsA, or low disease activity using DAPSA if peripheral arthritis.
Treat to target
Clinicians must aim to achieve MDA in all patients as soon as possible – aiming for 50% improvement in disease activity score within 3 months, and target reached by 6 months. A treat-to-target paradigm should be followed to achieve this. This strategy entails:
- use of composite disease activity score (global assessment of PsA or DAPSA if peripheral arthritis) at each visit
- frequent follow-up every 1 - 3 months in the first 6 - 18 months of treatment
- escalation or switching of therapy until the goal is achieved (Table 3).
| Table 3. Stepwise algorithm for therapy in psoriatic arthritis | ||||
| Therapy | Peripheral arthritis/dactylitis | Enthesitis | Axial disease | Inadequate response within 3 months |
| First-line therapy | Polyarthritis: MTX (other csDMARDs if MTX not tolerated/contraindicated) Mono-/oligoarthritis: intraarticular GC and NSAIDs |
NSAIDs | NSAID | Proceed to second-line therapy |
| GC injection | ||||
| MTX | ||||
| Second-line therapy | Combination or switch csDMARD | b/tsDMARD (TNFi/IL-17i/ JAKi/IL-12-23i/IL-23i/PDE4i/ abatacept) | b/tsDMARD (TNFi/IL-17i/ JAKi) | Proceed to third-line therapy |
| Third-line therapy | b/tsDMARD (TNFi/IL-17i/ JAKi/IL-12-23i/IL-23i/PDE4i/ abatacept) | Alternative b/tsDMARD (TNFi/IL-17i/JAKi/IL-12-23i/ IL-23i/PDE4i/abatacept) | Alternative b/tsDMARD (TNFi/IL-17i/JAKi) | Proceed to third-line therapy |
| Fourth-line therapy | Alternative b/tsDMARD | - | ||
| De-escalation | After sustained remission for 6 months, consider slow taper of b/tsDMARD, maintain csDMARD | Restart b/tsDMARD if flares | ||
| MTX = methotrexate; DMARD = disease-modifying antirheumatic drug; csDMARD = conventional synthetic DMARD; GC = glucocorticoid; NSAID = non-steroidal anti-inflammatory drug; b/tsDMARD = biologic/targeted synthetic DMARD; TNFi = tumour necrosis factor inhibitor; IL-17i = interleukin-17 inhibitor; IL-12-23i = interleukin 12/23 inhibitor; IL-23i = interleukin-23 inhibitor; JAKi = Janus kinase inhibitor; PDE4i = phosphodiesterase-4 inhibitors. | ||||
Benitha, R., Maharaj, A. B., Makan, K., Potts, J., Lai, A., Carter, R., van Dam, M., & Hodkinson, B. (2024). South African Rheumatism and Arthritis Association 2024 guidelines for the management of peripheral spondyloarthritis. South African Medical Journal, 114(10), e2669.